Case report Suprapubic cystostomy: a bizarre complication of catheter migration causing ureteric obstruction Dr. Pankaj P. Dangle, MD, Mch; Dr. James Tycast, MD; Dr. Evalynn Vasquez, MD; Dr. Brian Geary, MD; Dr. Micheal Chehval, MD Abstract The patient had a significant past medical history of right Suprapubic catheters are used routinely for bladder drainage; how- radical nephrectomy for Wilm’s tumour at childhood. The ever, complications are commonly reported. These complications hypercontractile neurogenic bladder was simultaneously could be attributed to surgical technique or the catheter itself. treated with anticholinergic in the form of oxybutynin. After Complications related to surgical technique can be controlled and the initial presentation and diagnosis of the UPJ obstruc- reduced, but catheter-related complications are unavoidable and tion, the patient was treated with ureteric stent in view of unpredictable. We report a rare catheter-related complication lead- pain and solitary functioning kidney at which time the ure- ing to obstruction of the ureter in a solitary kidney in a patient teric orifice appeared to be normal and non-gaping. The with neurogenic bladder and voiding dysfunction managed with patient was scheduled for an elective open pyeloplasty. She suprapubic catheter drainage. presented (2 weeks prior to the scheduled surgery) with a sudden increased left abdominal pain and decreased urine output from the suprapubic tube for 24 hours. The patient Can Urol Assoc J 2010;4(5):E127-128 underwent a computed tomography (CT) of the abdomen and pelvis, which revealed increased hydronephrosis and a newly detected hydroureter compared with a previous CT Introduction scan performed 6 months prior to the current episode (Fig. 2). The pelvic scan revealed what appeared to be a migrated Suprapubic catheter drainage is frequently employed for the suprapubic catheter tube into left ureteral orifice and ureter. management of neurogenic bladder with voiding dysfunc- Due to findings on the CT scan and the patient’s symptoms, tion. Although it is a safe procedure, multiple intra- and the situation was treated as a solitary obstructed kidney, the postoperative complications, such as infection, bleeding, suprapubic catheter (18 French) was changed under aseptic and obstruction, are commonly reported.1 Less frequent precautions to drain 250 mL of clear urine. Subsequently, the complications, such as expulsion through bladder, bowel patient’s pain resolved and she was sent home on prophy- perforation, entero-cutaneous fistula, knotting of the catheter lactic antibiotics. The patient then underwent an uncompli- and catheter migration in a gaping ureter, are also report- cated open left Anderson-Hynes pyeloplasty with complete ed.2-8 We report another unusual complication of migration resolution of left renal pain. During the surgery, the ureter of suprapubic catheter into a previously normal non-gaping appeared non-dilated without any crossing vessel at the UPJ. intramural ureteral orifice of a solitary kidney. Discussion Case history Suprapubic cystostomy catheter drainage is a well-estab- A 50-year-old female with neurogenic bladder secondary lished procedure for managing neurogenic bladder with to multiple sclerosis managed with a chronic suprapubic voiding dysfunction. Multiple commonly observed compli- catheter for 6 months was admitted with acute exacerbation cations, such as bacteriuria, bleeding, and bladder calculi, of multiple sclerosis and symptoms of left-sided pyelonephri- are reported.9 Based on a meta-analysis comparing supra- tis. On admission, the patient was treated conservatively. pubic catheter tube versus transurethral catheter drainage, Further investigations revealed left-sided hydronephrosis the suprapubic route is more acceptable to patients and has without hydroureter, and it was determined that patient had reduced microbiological complications.10 a symptomatic left ureteropelvic junction (UPJ) obstruction Currently, appropriate placement of a suprapubic tube (Fig. 1). The diagnosis was confirmed on renal scan which can be confirmed cystoscopically. Singh and colleagues demonstrated t ½ time of 23 minutes with delayed excretion. reported a case of left pyelonephritis secondary to cath- CUAJ • October 2010 • Volume 4, Issue 5 E127 © 2010 Canadian Urological Association Dangle et al. Fig 2. Computed tomography (CT) demonstrating the catheter migration in serial cuts as the catheter is seen in all sections with dilated ureter (a) compared to the nondilated ureter in CT scan done 6 months prior to the current scan (b). Fig 1. Lasix renograms demonstrating t ½ of 23 minutes with delayed excretion, explicitly demonstrated in the excretory films with excretion beyond 33 minutes. Competing interests: None declared. eter migration in a young male with a suprapubic catheter This paper has been peer-reviewed. inserted for traumatic urethral stricture. Cystographic evalu- ation revealed contrast entering the left ureter with bilateral hydronephrosis. The author hypothesized the possibility of migration of catheter in a gaping ureter with bilateral References hydronephrosis.8 Similarly, Parikh and colleagues reported a case of urinary retention secondary to suprapubic catheter 1. Ahluwalia RS, Johal N, Kouriefs C, et al. The surgical risk of suprapubic catheter insertion and long-term migration into the prostatic urethra.7 sequelae. Ann R Coll Surg Engl 2006;88:210-3. 2. Vaidyanathan S, Hughes PL, Soni BM. Unusual complication of suprapubic cystostomy in a male patient In our case, the patient had a neurogenic bladder second- with tetraplegia: traction on Foley catheter leading to extrusion of Foley balloon from urinary bladder ary to multiple sclerosis managed with a suprapubic catheter and suprapubic urinary fistula--importance of securely anchoring suprapubic catheter with adhesive tape and presented with catheter migration into left ureteral orifice or BioDerm tube holder. ScientificWorldJournal 2007;7:1575-8. leading to left hydronephrosis and obstructive uropathy. This 3. Vaidyanathan S, Hughes PL, Soni BM, et al. Hourglass urinary bladder in a spinal cord injury patient - is hypothesized based on the new onset left ureteral dilation unusual late complication of suprapubic cystostomy: a case report. Cases J 2009;2:6866. 4. Ananthakrishnan K, Ayyathurai R, Chiran JK, et al. An unusual complication of suprapubic catheter insertion. compared to previous CT scans. The presence of neurogenic ScientificWorldJournal 2006;6:2433-5. bladder could lead to detrussor over activity leading to migra- 5. Ahmed SJ, Mehta A, Rimington P. Delayed bowel perforation following suprapubic catheter insertion. tion of the catheter tip into the ureteral orifice. Since the BMC Urol 2004;4:16. patient had a solitary kidney, diagnosing such a condition 6. Farook SA, Kariholu U, Kousidis G, et al. Not to knot a catheter. Case report of the knotting of a suprapubic is crucial for immediate relief to the obstructed kidney. catheter. ScientificWorldJournal 2007;7:1004-6. 7. Parikh AM, Chapple CR. Suprapubic catheter--an unusual cause of acute retention. Br J Urol 1993;71:494-5. 8. Singh DR, Sailo L, Abraham NB, et al. An unusal complication of percutaneous suprapubic cystostomy. Conclusion Ind J Urol 2001;2:179-80. 9. Katsumi HK, Kalisvaart JF, Ronningen LD, et al. Urethral versus suprapubic catheter: choosing the In patients with neurogenic bladder with voiding dysfunction best bladder management for male spinal cord injury patients with indwelling catheters. Spinal Cord managed with suprapubic cystostomy, obstructive uropathy 2010;48:325-9. 10. McPhail MJ, Abu-Hilal M, Johnson CD. A meta-analysis comparing suprapubic and transurethral catheteriza- in a solitary functioning kidney should raise the suspicion tion for bladder drainage after abdominal surgery. Br J Surg 2006;93:1038-44. of a migrated catheter into the ureteral orifice. Correspondence: Dr. Pankaj P. Dangle, Department of Urology, Saint Louis University Hospital, Department of Urology, Saint Louis University Hospital, Saint Louis, MO 3635 Vista At Grand Blvd, Saint Louis, MO 63110; [email protected] E128 CUAJ • October 2010 • Volume 4, Issue 5.